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Spinal Manipulation in the Treatment of Low-Back Pain

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Abstract and Figures

Spinal manipulation, one of the oldest forms of therapy for back pain, has mostly been practiced outside of the medical profession. Over the past decade, there has been an escalation of clinical and basic science research on manipulative therapy, which has shown that there is a scientific basis for the treatment of back pain by manipulation. Most family practitioners have neither the time nor inclination to master the art of manipulation and will wish to refer their patients to a skilled practitioner of this therapy. Results of spinal manipulation in 283 patients with low back pain are presented. The physician who makes use of this resource will provide relief for many patients.
Content may be subject to copyright.
W.
H.
Kirkaldy-Willis
J.
D.
Cassidy
Spinal
Manipulation
in
the
Treatment
of
Low-Back
Pain
SUMMARY
Spinal
manipulation,
one
of
the
oldest
forms
of
therapy
for
back
pain,
has
mostly
been
practiced
outside
of
the
medical
profession.
Over
the
past
decade,
there
has
been
an
escalation
of
dlinical
and
basic
science
research
on
manipulative
therapy,
which
has
shown
that
there
is
a
scientific
basis
for
the
treatment
of
back
pain
by
manipulation.
Most
family
practitioners
have
neither
the
time
nor
inclination
to
master
the
art
of
manipulation
and
will
wish
to
refer
their
patients
to
a
skilled
practitioner
of
this
therapy.
Results
of
spinal
manipulation
in
283
patients
with
low
back
pain
are
presented.
The
physician
who
makes
use
of
this
resource
will
provide
relief
for
many
patients.
(Can
Fam
Physician
1985;31:535-540)
SOMMAIRE
Les
manipulations
vertebrales,
qui
sont
l'une
des
formes
les
plus
anciennes
de
traitement
pour
la
lombalgie,
ont,
dans
la
majorite
des
cas,
ete
l'apanage
de
professions
autres
que
medicales.
Au
cours
de
la
dernire
decennie,
la
recherche
fondamentale
et
clinique
sur
les
manipulations
s'est
accelerde
et
a
pu
demontrer
qu'il
existe
une
base
scientifique
pour
justifier
le
traitement
de
la
lombalgie
par
la
manipulation.
La
plupart
des
mddecins
de
famille
manquent
soit
de
temps,
soit
d'int6rkt
pour
maitriser
l'art
des
manipulations
et
pr6freront
rdferer
leurs
patients
aux
praticiens
possedant
l'expdrience
de
cette
forme
de
traitement.
Cet
article
presente
les
resultats
de
manipulations
vertebrales
chez
283
patients
souffrant
de
lombalgie.
Le
medecin
qui
utilise
cette
forme
de
traitement
contribuera
au
soulagement
de
nombreux
patients.
Key
words:
Spinal
manipulation,
low
back,
pain
Dr.
Kirkaldy-Willis
is
a
professor
emeritus
of
orthopedics
and
director
of
the
Low-Back
Pain
Clinic
at
the
University
Hospital,
Saskatoon.
Dr.
Cassidy
is
a
chiropractor
and
a
research
fellow
with
the
Department
of
Orthopedics
at
the
University
Hospital.
Reprint
requests
to:
Dr.
W.
H.
Kirkaldy-Willis,
Department
of
Orthopedics,
University
Hospital,
University
of
Saskatchewan,
Saskatoon,
SK.
S7N
OXO.
BACK
PAIN
is
one
of
the
com-
monest
presenting
complaints
in
office
practice:
almost
80%
of
the
general
population
will
experience
low
back
pain
during
adult
life.
At
any
given
time,
20-30%
of
adults
suf-
fer
from
low
back
pain.
",
2
In
in-
dustry,
disorders
of
the
lower
back
account
for
four
hours
per
year
per
worker
of
lost
productivity,
and
rank
CAN.
FAM.
PHYSICIAN
Vol.
31:
MARCH
1985
second
only
to
upper
respiratory
in-
fection
as
a
cause
of
absenteeism.3
Patients
with
low
back
pain
represent
a
major
segment
of
the
chronically
disabled,
comparable
to
the
numbers
suffering
from
heart
disease,
arthritis
and
rheumatism.3
Estimates
for
the
cost
of
treatment
and
compensation
in
the
United
States
for
those
suffering
from
back
pain
exceed
$14
billion
an-
nually-notwithstanding
the
cost
of
lost
productivity
in
the
work
place.
2
Despite
the
high
frequency
and
enormous
cost
of
low
back
pain,
the
causes
and
effective
therapeutic
pro-
grams
remain
highly
problematic.
Part
of
this
problem
is
due
to
the
na-
ture
of
low
back
pain:
it
is
a
common,
self-limiting
disorder
with
a
high
rate
of
recurrence.4
Moreover,
the
many
different
causes
of
back
pain
are
not
always
readily
apparent.
In
fact,
with
the
exception
of
back
pain
and
scia-
tica
resulting
from
entrapment
of
the
spinal
nerve
root
by
degenerative
changes
or
by
disc
herniation,
most
causes
of
low
back
pain
lack
objective
clinical
signs
and
overt
pathological
changes.
Nevertheless,
these
obscure
causes
are
responsible
for
most
of
the
back
pain
seen
in
clinical
practice.3
Less
than
10%
of
low
back
pain
is
due
to
herniation
of
the
intervertebral
disc
or
entrapment
of
spinal
nerves
by
degenerative
disc
disease.",4'5
Ac-
cordingly,
the
diagnosis
of
low
back
pain
is
a
difficult
matter.
We
attempt
to
group
back
pain
patients
into
syn-
drome
categories
on
the
basis
of
their
history,
pain
distribution,
physical
ex-
amination
and
radiographic
findings.6
By
this
approach,
we
try
to
identify
the
predominant
pain-producing
le-
sion
and
direct
our
treatment
accord-
ingly.
Although
this
method
is
clini-
cally
useful,
it
does
not
necessarily
reflect
true
pathogenesis.
Since
most
low
back
pain
is
idio-
pathic,
the
effects
of
many
commonly
applied
therapies
remain
highly
spec-
535
I
ulative.
This
is
true
for
such
popular
treatments
as
spinal
fusion,
chemonu-
cleolysis,
facet
injection
and
denerva-
tion,
transcutaneous
electrical
nerve
stimulation,
acupuncture,
exercise,
traction,
manipulation
and
so
on.
One
could
argue
that
spinal
fusion
relieves
pain
by
denervating
spinal
structures
rather
than
by
stabilizing
an
unstable
motion
segment.
Perhaps
extensive
operative
procedures
relieve
back
pain
by
lowering
intraosseous
venous
hy-
pertension
or
by
enforcing
bed
rest
and
a
planned
period
of
rehabilita-
tion.7
Moreover,
spinal
fusion
has
not
been
subjected
to
rigorous
clinical
trial.8
This
is
also
true
for
many
other
therapies.
Furthermore,
the
natural
history
of
low
back
pain
ensures
a
good
longterm
result
despite
treat-
ment.9
Therefore,
it
is
wise
to
begin
the
treatment
of
low
back
pain
with
a
safe,
cost-effective,
conservative
pro-
gram
of
therapy
and
to
proceed
to
more
expensive
and
invasive
proce-
dures
in
carefully
selected
patients
only.
What
is
Spinal
Manipulation?
Spinal
manipulation
is
essentially
an
assisted
passive
motion
applied
to
the
spinal
apophyseal
and
sacroiliac
joints.
The
terms
mobilization
and
manipulation
require
separate
defini-
tions.10
In
Figure
one,
the
motion
of
a
synovial
joint
is
shown
in
one
plane.
Beyond
the
end
of
the
active
range
of
motion
(ROM)
of
any
synovial
joint,
there
is
a
small
buffer
zone
of
passive
mobility.
A
joint
can
be
only
pas-
sively
assisted
into
this
ROM.
This
constitutes
mobilization.
At
the
end
of
the
passive
ROM,
an
elastic
barrier
of
resistance
is
encoun-
tered.
This
barrier
has
a
spring-like
end-feel
which
is
the
result
of
a
nega-
tive
or
subatmospheric
intra-articular
pressure.
This
negative
pressure
is
a
stabilizing
factor
in
the
coaptation
of
the
articular
surfaces.
If
the
separation
of
the
articular
surfaces
is
forced
beyond
this
elastic
barrier,
the
joint
surfaces
suddenly
move
apart
with
a
cracking
noise.
This
additional
sepa-
ration
can
only
be
achieved
after
cracking
the
joint
and
has
been
la-
belled
the
paraphysiological
ROM.
This
constitutes
manipulation.
The
cracking
sound
on
entering
the
paraphysiological
ROM
is
the
result
of
the
sudden
liberation
of
synovial
gases-a
phenomenon
known
to
536
physicists
as
cavitation.11
The
resul-
tant
synovial
bubble
can
be
demon-
strated
radiographically
and
is
reab-
sorbed
over
the
following
30
minutes.
During
this
period,
the
elastic
barrier
of
resistance
between
the
passive
and
paraphysiological
zones
is
absent,
and
there
is
an
increase
in
the
joint
space.
As
the
synovial
gases
are
reabsorbed,
the
intra-articular
pressure
drops,
the
joint
space
narrows,
and
the
elastic
barrier
of
resistance
is
re-established
between
the
passive
and
paraphysiolo-
gical
zones.
During
this
refractory
period,
the
joint
is
somewhat
unstable
and
cannot
be
remanipulated
safely.
At
the
end
of
the
paraphysiological
ROM,
the
limit
of
anatomical
integ-
rity
is
encountered.
Movement
beyond
this
limit
results
in
damage
to
the
capsular
ligaments.
During
manip-
ulation,
a
carefully
graded
and
directed
thrust
is
applied
across
the
joint
space
at
the
end
of
the
passive
ROM.
This
force
must
be
great
enough
to
overcome
the
elastic
barrier
of
resistance,
but
not
so
great
as
to
separate
the
joint
surfaces
beyond
their
limit
of
anatomical
integrity.
This
requires
precise
positioning
of
the
joint
at
the
end
of
the
passive
ROM
and
the
proper
degree
of
force
to
overcome
joint
coaptation.
This
skill
is
not
easily
acquired;
consider-
able
training
and
experience
are
nec-
essary.
In
the
hands
of
a
skilled
mani-
pulator,
the
procedure
is
not
painful.
Most
lumbar
spine
manipulations
are
done
with
the
patient
in
the
side
posture
position
(see
Fig.
2).
In
this
position,
the
knee
and
hip
of
the
upper
leg
are
flexed
on
the
lower
leg.
This
enables
the
upper
thigh
to
be
used
as
a
lever.
In
the
side
posture,
the
lumbar
lordosis
is
reduced,
and
the
spine
is
relatively
straight.
To
begin
the
process
of
mobiliza-
tion
and
manipulation,
the
patient's
upper
body
is
twisted
to
introduce
an
element
of
rotation
and
lateral
flexion
into
the
lumbar
spine
(see
Fig.
3).
In
this
position,
there
is
a
counter-
rotation
of
the
upper
torso
on
the
pelvis,
and
the
posterior
facet
joints
are
at,
or
near,
their
limit
of
active
ROM.
During
the
next
step,
the
mani-
pulator
must
try
to
localize
the
point
of
counter-rotation
to
the
motion
seg-
ment
to
be
manipulated,
by
varying
the
degree
of
flexion
in
the
upper
knee and
hip.
(see
Fig.
4).
This,
in
turn,
varies
the
degree
of
tension
placed
on
the
lower
lever
and
the
point
of
counter-rotation
between
the
two
levers.
By
increasing the
tension
on
the
lower
lever,
the
force
of
the
manipulation
can
be
localized
to
higher
levels
of
the
lumbar
spine.
With
experience,
the
manipulator
can
be
very
specific
in
selecting
the
spinal
level
to
be
manipulated.
Once
the
force
of
the
manipulation
has
been
localized,
the
process
of
mo-
bilization
and
then
manipulation
can
begin.
With
the
patient
rotated
in
the
side
posture,
the
counter-rotation
force
on
the
spine
can
be
increased
through
the
passive
ROM
up
to
the
elastic
barrier
of
resistance
(see
Fig.
5).
This
constitutes
spinal
mobiliza-
tion
and
can
be
repeated
several
times
with
increasing
force.
If
enough
force
is
applied
to
overcome
joint
coapta-
tion,
a
crack
is
produced,
and
the
ROM
is
increased
into
the
paraphys-
iological
zone
(see
Fig.
6).
An
experi-
enced
manipulator
can
overcome
the
elastic
barrier
of
resistance
with
a
carefully
applied,
high-velocity,
short-amplitude
thrust.
Less
experi-
enced
clinicians
should
master
the
art
of
mobilization
before
attempting
to
manipulate
the
spine.
What
are
the
Effects
of
Spinal
Manipulation?
Research
into
the
effects
of
spinal
manipulation
has
escalated
over
the
past
decade,12-15
partly
due
to
in-
creased
understanding
of
articular
neu-
rology
and
pain
modulation.
Melzack
and
Wall16
first
proposed
the
gate
theory
of
pain
in
1965.
Since
that
time,
the
basic
principles
of
this
theory
have
withstood
rigorous
scien-
tific
scrutiny-even
if
the
precise
mechanisms
and
anatomical
details
are
not
fully
understood.
In
essence,
they
proposed
a
spinal
gating
mechanism
within
the
substantia
gelatinosa
(Rexed's
lamina
II)
of
the
dorsal
horn
of
the
spinal
cord.
This
gate
controls
the
central
transmission
of
sensory
in-
formation
including
pain,
touch,
tem-
perature
and
proprioception.
They
have
shown
that
the
central
transmis-
sion
of
pain
can
be
blocked
by
in-
creased
proprioceptive
input
and
facilitated
by
a
lack
of
proprioceptive
input.
This
simple
concept
explains
why
rubbing
an
acute
injury
alleviates
the
pain
and
the
importance
of
early
mobilization
to
control
pain
after
mus-
culosketetal
injury.
Wyke1
7
has
shown
that
the
articular
capsules
of
the
spinal
facet
joints
are
densely populated
by
mechanorecep-
tors.
These
encapsulated
nerve
end-
CAN.
FAM.
PHYSICIAN
Vol.
31:
MARCH
1985
Fig.
1Fig.4
Fig.
2
Fig.
3
SIDE
POSTURE:
Limit
of
Active
R.O.M.
COUNTER-ROTATION
of
LEVERS
CAN.
FAM.
PHYSICIAN
Vol.
31:
MARCH
1985
JOINT
MOBILIZATION
and
MANIPULATION
N
ACTIVE
R.O.M.
El
PASSIVE
R.O.M.
*
PARAPHYSIOLOGICAL
9f
:00
:0:
},
~~~~R.O.M.
'
I,..
'-
MOBIL
(ZAtrSdN
''
96
'.
MANIPUJLATION
w
(Aftter
Sandoz,
1976)
Segmental
Localization
of
Force
(i)
14-5
(.
)
o
2-
'
H
a
E
tHIP
and
KNEE
FLEXIO
SIDE
POSTURE:
Neutral
Position
Fig.
5
Fig.
6
SIDE
POSTURE:
Limit
of
Passive
R.O.M.
MOBILIZATION
SIDE
POSTURE:
Limit
of
Paraphysiological
R.O.M.
../
MNIPULATION
Fig.
I
Fig.
4
537
ings
relay
proprioceptive
information
on
joint
position
and
mobility
through
large
myelinated
fibers
to
the
substan-
tia
gelatinosa
of
the
spinal
cord.
These
impulses
then
compete
for
central
transmission
with
impulses
from
the
smaller
unmyelinated
pain
fibers
from
adjacent
tissues.
Hence,
increased
pro-
prioceptive
input
in
the
form
of
spinal
mobility
tends
to
decrease
the
central
transmission
of
pain
from
adjacent
spi-
nal
structures
by
closing
the
gate.
Any
therapy
which
induces
motion
into
ar-
ticular
structures
will
help
to
inhibit
pain
transmission
by
this
means.
18
Wyke
and
others
19-21
have
also
shown
that
articular
mechanoreceptor
stimulation
has
a
reflexogenic
effect
on
motor
unit
activity
in
the
muscles
operating
over
the
joint
being
stimu-
lated.
Stretching
of
apophyseal
joint
capsules
can
therefore
reflexly
inhibit
facilitated
motoneuron
pools
which
are
responsible
for
the
increased
muscle
excitability
and
spasms
that
commonly
accompany
low
back
pain.
In
more
chronic
cases,
there
is
short-
ening
of
periarticular
connective
tissue
and
intra-articular
adhesions
may
form.22'
23
We
believe
that
in
some
cases,
manipulation
will
stretch
or
break
these
adhesions.
In
fact,
in
most
cases
of
chronic
low
back
pain,
there
is
an
initial
increase
in
symptoms
after
the
first
few
manipulations.
In
almost
all
cases,
however,
this
increase
in
pain
is
temporary
and
can
be
easily
controlled
by
local
application
of
ice.
However,
the
gain
in
mobility
must
be
TABLE
1
Results
of
Spinal
Manipulation
in
54
Patients
with
Posterior
Joint
Syndrome
Average
duration
of
pain
5.6
yrs.
Average
length
of
follow-up
9.2
mo.
Results:
Grade
64%
Grade
2
15%
Grade
3
9%
Grade
4
120/o
TABLE
2
Results
of
Spinal
Manipulation
in
69
Patients
with
Sacroiliac
Joint
Syndrome
Average
duration
of
pain
7.9
yrs.
Average
length
of
follow-up
10.3
mo.
Results:
Grade
1
71%
Grade
2
22%
Grade
3
3%
Grade
4
4%
maintained
during
this
period
to
pre-
vent
further
adhesion
formation.
Through
these
mechanisms,
spinal
manipulation
can
break
the
cycle
of
pain,
muscle
spasm
and
immobility
which
predominates
in
many
cases
of
low
back
pain.
At
present,
there
is
no
evidence
that
manipulation
replaces
sublexated
ver-
tebrae.
This
theory
was
first
put
for-
ward
by
the
chiropractic
profession
many
years
ago
and
has
largely
been
abandoned.
However,
changes
in
epi-
durographic
defects
have
been
re-
ported
after
manipulation,24
although
a
similar
study
using
myelography
showed
no
changes
in
the
defects,
yet
over
50%
of
the
patients
studied
were
improved
by
manipulation.25
More
re-
cently,
manipulative
therapy
was
shown
to
be
superior
to
shortwave
diathermy
and
exercise
in
a
rando-
mized
controlled
clinical
trial
on
pa-
tients
with
prolapsed
intervertebral
discs.26
Our
own
studies
and
those
of
others
suggest
that
success
with
mani-
pulative
therapy
decreases
with
in-
creasing
neurological
deficit.27'
28
We
would
therefore
not
recommend
mani-
pulative
therapy
in
cases
of
prolapsed
disc
with
marked
neurological
deficit.
How
Successful
is
Spinal
Manipulation?
Since
1952,
there
have
been
over
50
clinical
trials
of
spinal
manipulation
for
back
pain.29
Of
these
studies,
13
are
randomized
controlled
clinical
trials.
Although
some
of
these
studies
show
faults
in
design
and
some
degree
of
variability
in
the
results,
certain
trends
are
emerging.
In
the
treatment
of
acute
low
back
pain,
most
studies
show
that
manipula-
tion
tends
to
shorten
the
episode
of
pain,30
31
particularly
over
the
short
term.
Longterm
follow-up
suggests
that
the
initial
advantage
of
manipula-
tion
over
other
therapies
is
lost
with
time.
This
is
also
true
for
other
treat-
TABLE
3
Results
of
Spinal
Manipulation
in
48
Patients
with
combined
Posterior
Joint
and
Sacroiliac
Joint
Syndromes
Average
duration
of
pain
9.8
yrs.
Average
length
of
follow-up
13.9
mo.
Results:
Grade
1
67%
Grade
2
21%
Grade
3
6%
Grade
4
6%
ment
and
is
consistent
with
the
recur-
rent
nature
of
low
back
pain.
Similar
findings
have
been
reported
for
the
treatment
of
chronic
low
back
pain
by
manipulation.32'
33
In
most
cases,
there
is
an
initial
improvement
followed
by
a
regression
to
the
mean.
These
findings
suggest
that
although
spinal
manipulation
is
successful
in
al-
leviating
low
back
pain,
it
does
not
af-
fect
the
recurrent
nature
of
the
dis-
order.
Similarly,
discectomy
for
lumbar
disc
herniation
results
in
re-
gression
to
the
mean
over
a
longer
time.34
Several
points
should
be
made
about
clinical
trials
of
manipulation.
In
most
cases,
the
method
of
manipulation
is
not
described;
many
of
these
trials
uti-
lized
mobilization
rather
than
manipu-
lation.
In
a
majority
of
the
studies,
very
few
treatments
were
given,
and
the
training
and
expertise
of
the
mani-
pulators
are
impossible
to
judge.
In
some,
there
are
obvious
design
errors
and
experimental
bias
is
likely.
In
others,
the
numbers
are
probably
too
small
to
show
significance.
Neverthe-
less,
there
is
ample
evidence
that
spi-
nal
manipulation
is
a
useful
therapy
deserving
further
study.
Which
is
the
Best
Back
to
Manipulate?
Many
attempts
have
been
made
to
identify
patients
who
will
best
respond
to
manipulative
therapy.
Jayson
et
al.
were
unable
to
identify
any
prognostic
markers
other
than
a
shorter
history
of
pain.35
Evans
et
al.
found
that
patients
benefiting
from
manipulation
were
more
likely
to
be
older
and
to
have
had
symptoms
for
a
shorter
period.32
The
same
group
was
unable
to
predict
treatment
outcome
on
the
basis
of
ra-
diographic
findings.36
In
a
retrospec-
tive
study,
Morrison28
identified
sev-
eral
parameters
for
success,
including
a
sudden
onset
of
back
or
leg
pain,
re-
duced
spinal
mobility,
straight
leg
TABLE
4
Results
of
Spinal
Manipulation
in
31
Patients
with
Posterior
Joint
Syndrome
and/or
Sacroiliac
Joint
Syndrome
with
Lumbar
Instability
Average
duration
of
pain
7.2
yrs.
Average
length
of
follow-up
8.0
mo.
Results:
Grade
1
26%
Grade
2
19%
Grade
3
29%
Grade
4
26%
CAN.
FAM.
PHYSICIAN
Vol.
31:
MARCH
1985
538
raising
more
than
60
degrees
and
few
neurological
signs.
Others
have
been
unable
to
differentiate
responders
from
non-responders.
33'
37,
38
We
recently
completed
a
prospect-
ive
observational
study
of
spinal
ma-
nipulation
in
283
patients
with
chronic
low
back
and
leg
pain.
The
results
of
this
study
are
summarized
in
Tables
1-7.
Details
on
our
diagnostic
criteria
and
method
of
study
are
available
else-
where.27
Our
patient
population
was
taken
from
a
specialized
university
back
pain
clinic
reserved
for
patients
who
have
not
responded
to
previous
conservative
or
operative
treatment.
All
of
the
patients
in
this
study
were
totally
disabled
(grade
4
disability)
at
the
onset
of
treatment.
Therefore,
our
results
might
not
be
representative
of
similar
treatment
given
in
primary
care
to
patients
who
are
not
totally
disa-
bled.
In
our
study,
the
patient's
response
to
treatment
was
assessed
by
an
inde-
pendent
observer
and
based
on
the
pa-
tient's
impression
of
pain
relief
and
loss
of
disability.
The
results
were
graded
as
follows:
Grade
I.
Symptom-free
with
no
re-
strictions
for
work
or
other
activities.
Grade
2.
Mild
intermittent
pain
with
no
restrictions
for
work
or
other
activi-
ties.
Grade
3.
Improved,
but
restricted
in
activities
by
pain.
Grade
4.
Constant
severe
pain;
dis-
ability
unaffected
by
treatment.
All
patients
entered
the
study
at
the
grade
4
level
of
pain
and
disability.
They
were
given
a
two
or
three
week
regimen
of
daily
spinal
manipulations
by
an
experienced
chiropractor.
The
results
of
this
treatment
were
assessed
one
month
later
and
at
three
month
in-
tervals
thereafter.
No
patients
were
made
worse
by
manipulation,
yet
many
experienced
an
increase
in
pain
during
the
first
week
of
treatment.
Patients
undergo-
TABLE
5
Results
of
Spinal
Manipulation
in
60
Patients
with
Nerve
Root
Entrapment
Syndrome
Average
duration
of
pain
7.2
yrs.
Average
length
of
follow-up
14.0
mo.
Results:
Grade
1
25%
Grade
2
25%
Grade
3
17%
Grade
4
330/o
ing
manipulative
treatment
must
there-
fore
be
reassured
that
the
initial
dis-
comfort
is
only
temporary.
In
our
experience,
anything
less
than
two
weeks
of
daily
manipulation
is
inade-
quate
for
chronic
back
pain
patients.
Our
results
are
summarized
in
Table
8.
Patients
grouped
under
the
referred
pain
syndromes
include
those
with
posterior
joint
and
sacroiliac
syn-
dromes.
These
patients
may
present
with
low
back
and/or
leg
pain,
but
have
no
signs
of
radiculopathy.
The
designation
of
posterior
joint
or
sacro-
iliac
syndrome
does
not
necessarily
reflect
pathogenesis,
but
rather
the
structures
that
were
manipulated.
The
patients
grouped
under
nerve
compression
syndromes
include
those
with
nerve
root
entrapment
syndrome
and
a
small,
select
group
of
patients
with
central
spinal
stenosis
syndrome
who
were
unfit
for
surgery.
These
pa-
tients
all
had
evidence
of
radiculo-
pathy;
most
presented
with
leg
pain.
The
level
of
manipulation
in
this
group
was
determined
by
criteria
outlined
elsewhere.39
If
we
consider
a
grade
1-2
response
to
treatment
as
clinically
significant,
a
significantly
better
result
was
obtained
in
the
referred
pain
syndromes.
We
also
found
that
patients
with
low
back
and/or
proximal
sciatica
(pain
not
past
the
knee)
responded
significantly
bet-
ter
than
those
with
distal
sciatic
radia-
tion
of
pain
(p<0.001).
In
one
group
of
patients
(Table
4),
radiographic
evi-
dence
of
motion
segment
instability
(as
diagnosed
from
lateral
views
taken
at
the
extremes
of
lumbar
flexion
and
extension)
was
associated
with
a
signi-
ficantly
poorer
response
to
manipula-
tion
(p<0.01).40
Almost
25%
of
our
patients
had
undergone
previous
surgi-
cal
treatment
for
their
back
pain,
and
although
there
was
a
trend
towards
a
poorer
response
to
treatment,
it
was
not
statistically
significant.
This
was
TABLE
6
Results
of
Spinal
Manipulation
in
Ten
Patients
with
Nerve
Root
Entrapment
Syndrome
with
Lumbar
Instability
Average
duration
of
pain
11.5
yrs.
Average
length
of
follow-up
12.6
mo.
Results:
Grade
1
40%
Grade
2
10%
Grade
3
20%
Grade
4
30%/
also
true
for
the
degree
of
degenerative
disc
disease
seen
on
the
X-ray.
Who
Should
Deliver
Manipulative
Therapy?
Several
professional
groups
offer
manipulative
therapy;
of
these,
chiro-
practors
are
the
largest.
Most
provin-
cial
health
care
plans
insure
their
care.
Recently,
the
physiotherapy
profes-
sion
has
become
more
interested
in
providing
this
care.
Many
undergrad-
uate
physiotherapy
colleges
now
offer
training
in
mobilization
and
manipula-
tion.
In
the
United
States,
some
osteo-
paths
still
provide
manipulative
care
as
part
of
their
allopathic
practices.
Some
physicians
practice
manipulative
med-
icine
fulltime;
most
are
members
of
the
North
American
Academy
of
Man-
ipulative
Medicine
which
offers
post-
graduate
training.
It
is
not
difficult
to
obtain
manipulative
treatment
in
most
North
American
and
European
centres.
Manipulation
requires
much
prac-
tice
to
acquire
the
necessary
skills
and
competence.
It
is
a
fulltime
vocation:
few
medical
practitioners
have
the
time
or
inclination
to
master
it.
Most
doctors,
whether
family
physicians
or
surgeons,
will
wish
to
refer
their
pa-
tients
to
a
practitioner
of
manipulative
therapy
with
whom
they
can
cooper-
ate,
whose
work
they
know
and
whom
they
can
trust.
The
professional
back-
ground
of
these
practitioners
may
vary
from
case
to
case.
The
physician
who
makes
use
of
this
resource
will
provide
relief
for
many
back
pain
patients.
)
References
1.
Valkenburg
HA,
Haanen
HCM.
The
epi-
demiology
of
low-back
pain.
In:
White
AA,
Gordon
SL,
eds.
American
Academy
of
Orthopaedic
Surgeons
Symposium
on
Idio-
pathic
Low
Back
Pain.
Toronto:
CV
Mosby
Co.,
1982:9-22.
2.
White
AA.
Introduction.
In:
White
AA,
Gordon
SL,
eds.
American
Academy
of
TABLE
7
Results
of
Spinal
Manipulation
in
11
Patients
with
Central
Spinal
Stenosis
Syndrome
Average
duration
of
pain
16.9
yrs.
Average
length
of
follow-up
7.0
mo.
Results:
Grade
1
18%
Grade
2
18%
Grade
3
18%
Grade
4
46%8
CAN.
FAM.
PHYSICIAN
Vol.
31:
MARCH
1985
539
Orthopaedic
Surgeons
Symposium
on
Idio-
pathic
Low
Back
Pain.
Toronto:
CV
Mosby
Co.,
1982:1-2.
3.
Kelsey
JL.
Idiopathic
low-back
pain:
magnitude
of
the
problem.
In:
White
AA,
Gordon
SL,
eds.
American
Academy
of
Orthopaedic
Surgeons
Symposium
on
Idio-
pathic
Low
Back
Pain.
Toronto:
CV
Mosby
Co.,
1982:5-8.
4.
Kelsey
JL.
Epidemiology
of
musculo-.
skeletal
disorders.
New
York:
Oxford
Uni-
versity
Press,
1982:145-67.
5.
Frymoyer
JW,
Newberg
A,
Pope
MH,
Wilder
DG,
Clements
J,
MacPherson
B.
Spine
radiographs
in
patients
with
low-
back
pain.
J
Bone
Joint
Surg
1984;
66-
A:1048-55.
6.
Kirkaldy-Willis
WH,
ed.
Managing
low-
back
pain.
New
York:
Churchill
Living-
stone,
1983.
7.
Foley
RK,
Kirkaldy-Willis
WH.
Chronic
venous
hypertension
in
the
tail
of
the
wistar
rat.
Spine
1979;
4:251-7.
8.
Farfan
HF,
Kirkaldy-Willis